Establishing an out-of-hospital cardiac arrest registry in China: a key first step to improving outcomes
Authors: Adam Mellett-Smith, Keith Couper
Journal: The Lancet Public Health (2023)

Across the world, there is an urgent need to improve outcomes from out-of-hospital cardiac arrest (OHCA). The community response plays a key role in improving OHCA outcomes through the early identification of cardiac arrest, contacting emergency services, initiating cardiopulmonary resuscitation, and delivering defibrillation before ambulance arrival. The cardiac arrest chain of survival conceptualises how these key early interventions, which optimise the likelihood of restarting the heart, interlock with post-resuscitation care to optimise quality of life following cardiac arrest.1Semeraro F Greif R Böttiger BW et al.European Resuscitation Council Guidelines 2021: systems saving lives.Resuscitation. 2021; 161: 80-97Summary Full Text Full Text PDF PubMed Scopus (154) Google Scholar, 2Nolan J Soar J Eikeland H The chain of survival.Resuscitation. 2006; 71: 270-271Summary Full Text Full Text PDF PubMed Scopus (200) Google Scholar The international resuscitation community has developed a range of strategies to optimise this community response to cardiac arrest, including training children in cardiopulmonary resuscitation, international calls to action such as World Restart a Heart Day, the development of community first responder schemes, and the optimisation of defibrillator placement.1Semeraro F Greif R Böttiger BW et al.European Resuscitation Council Guidelines 2021: systems saving lives.Resuscitation. 2021; 161: 80-97Summary Full Text Full Text PDF PubMed Scopus (154) Google Scholar, 3Schroeder DC Semeraro F Greif R et al.Kids save lives: basic life support education for schoolchildren: a narrative review and scientific statement from the International Liaison Committee on Resuscitation.Resuscitation. 2023; 188109772Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 4Brooks SC Clegg GR Bray J et al.Optimizing outcomes after out-of-hospital cardiac arrest with innovative approaches to public-access defibrillation: a scientific statement from the International Liaison Committee on Resuscitation.Resuscitation. 2022; 172: 204-228Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar The rigorous collection of data in a cardiac arrest registry plays a key role in the drive to improve OHCA outcomes through the collection of baseline data to target areas for improvement, and then provides the opportunity to track success over time. In their Article, in The Lancet Public Health, Jiaqi Zheng and colleagues5Zheng J Lv C Zheng W et al.Incidence, process of care, and outcomes of out-of-hospital cardiac arrest in China: a prospective study of the BASIC-OHCA registry.Lancet Public Health. 2023; (published online Sept 15.)https://doi.org/10.1016/S2468-2667(23)00173-1PubMed Google Scholar describe the first results from the newly-established Chinese BASIC-OHCA cardiac arrest registry, which covers a population of approximately 115 million people. Although this represents only around 8% of the Chinese population, the authors describe how specific areas across different regions of China were targeted in an attempt to ensure the sample was broadly representative of the whole Chinese population. Overall, OHCA incidence was reported to be 95·7 per 100 000 person-years, of which resuscitation was attempted for 31·8% of patients. In a cohort of 35 090 patients with an unwitnessed or bystander witnessed OHCA, only 11·5% received dispatcher-assisted cardiopulmonary resuscitation, 20·3% received bystander cardiopulmonary resuscitation, and less than 0·1% had a defibrillator attached by a bystander. These limitations in the community response are likely key contributors to the very low rates of prehospital return of spontaneous circulation (3·4%), survival at 30-days (1·2%), and favourable neurological outcome (0·8%). In the Utstein comparator group (bystander-witnessed cardiac arrest with a shockable initial rhythm), which is designed to limit system differences in survival rates, 30-day survival was just 6·1%. Importantly, this report covers data collected from Aug 1, 2019, to Dec 31, 2020. The ongoing collection of data through the COVID-19 pandemic is a remarkable achievement. Nevertheless, previous studies have described the deleterious effect of the pandemic on OHCA, including increased incidence, poorer outcomes, and a decline in the community response to OHCA.6Chan PS Girotra S Tang Y Al-Araji R Nallamothu BK McNally B Outcomes for out-of-hospital cardiac arrest in the United States during the coronavirus disease 2019 pandemic.JAMA Cardiol. 2021; 6: 296-303Crossref PubMed Scopus (93) Google Scholar, 7Marijon E Karam N Jost D et al.Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: a population-based, observational study.Lancet Public Health. 2020; 5: e437-e443Summary Full Text Full Text PDF PubMed Scopus (341) Google Scholar Further work might be needed to explore to what extent the findings of this study were influenced by the pandemic. An International Liaison Committee on Resuscitation study, which included summary data from seven regional registries and nine national registries, highlighted wide international variability across systems in processes of care and outcomes.8Kiguchi T Okubo M Nishiyama C et al.Out-of-hospital cardiac arrest across the world: first report from the International Liaison Committee on Resuscitation (ILCOR).Resuscitation. 2020; 152: 39-49Summary Full Text Full Text PDF PubMed Scopus (227) Google Scholar For care processes, reported rates for bystander cardiopulmonary resuscitation ranged from 19·1% to 79·0% and for bystander defibrillation ranged from 2·0% to 37·4%, highlighting potential opportunities for China to optimise its community response to cardiac arrest. For outcomes, 30-day survival ranged from 11·7% to 47·4% in the Utstein comparator group and from 3·1% to 20·4% across all cardiac arrests. Epidemiological research in OHCA has, to date, come predominantly from high-income countries.8Kiguchi T Okubo M Nishiyama C et al.Out-of-hospital cardiac arrest across the world: first report from the International Liaison Committee on Resuscitation (ILCOR).Resuscitation. 2020; 152: 39-49Summary Full Text Full Text PDF PubMed Scopus (227) Google Scholar, 9Schnaubelt S Garg R Atiq H et al.Cardiopulmonary resuscitation in low-resource settings: a statement by the International Liaison Committee on Resuscitation, supported by the AFEM, EUSEM, IFEM, and IFRC.Lancet Glob Health. 2023; 11: e1444-e1453Summary Full Text Full Text PDF PubMed Google Scholar China, despite having one of the world's largest economies, is categorised by the World Bank as a middle-income country. The important contribution of this work by Zheng and colleagues5Zheng J Lv C Zheng W et al.Incidence, process of care, and outcomes of out-of-hospital cardiac arrest in China: a prospective study of the BASIC-OHCA registry.Lancet Public Health. 2023; (published online Sept 15.)https://doi.org/10.1016/S2468-2667(23)00173-1PubMed Google Scholar comes from both its large population coverage and its setting in a middle-income country. Nevertheless, key aspects of the Chinese emergency medical service response in China might not be typical of other low-income and middle-income countries, including the provision of dispatcher-assisted cardiopulmonary resuscitation, a standardised national emergency phone number, and a physician-led emergency medical service response. The specific challenges in improving outcomes from OHCA in low-income and middle-income countries were set out in a recently released policy statement led by the International Liaison Committee on Resuscitation, in collaboration with other key health-care societies.9Schnaubelt S Garg R Atiq H et al.Cardiopulmonary resuscitation in low-resource settings: a statement by the International Liaison Committee on Resuscitation, supported by the AFEM, EUSEM, IFEM, and IFRC.Lancet Glob Health. 2023; 11: e1444-e1453Summary Full Text Full Text PDF PubMed Google Scholar The statement highlights the need for a more global approach to improving OHCA outcomes and the need for a context-specific, stepwise approach to implementing strategies that improve outcomes from OHCA across the globe. Data collected through the BASIC-OHCA registry has identified key opportunities to improve OHCA outcomes in China through optimising the community response. Over the coming months and years, the registry will provide an important tool to track success and could facilitate the sharing of experience with other countries towards the beginning of their journey in improving outcomes from OHCA. KC reports volunteer roles with the International Liaison Committee on Resuscitation and the European Resuscitation Council. AM-S declares no competing interests. Incidence, process of care, and outcomes of out-of-hospital cardiac arrest in China: a prospective study of the BASIC-OHCA registryOur findings revealed a high burden of EMS-assessed OHCA with a low proportion of resuscitation attempts. The suboptimal implementation of chain of survival and unsatisfactory prognosis call for national efforts to improve the care and outcomes of patients with OHCA in China. Full-Text PDF Open Access